PERSON-CENTERED DIAGNOSIS:
PRINCIPLES AND PRACTICE
It is more important to know what person has the disease
than which disease the person has. —William Osler
The purpose of this paper is to present an organizational structure for assessment of patients as
unique individuals, an approach I have called person-centered diagnosis.1 The goal of PersonCentered Diagnosis is to enable healers to develop individualized treatment plans that are based
upon an understanding of the physiological, environmental, and psychosocial contexts within
which each person's illnesses or dysfunctions occur. You must start by eliciting all of the
patient's concerns. In actively listening to the patient's story, you attempt to discover the
antecedents, triggers and mediators that underlie symptoms, signs, illness behaviors, and
demonstrable pathology. Integrated medicine is based upon treatment that is collaborative,
flexible, and focused on the control or reversal of each person's individual antecedents, triggers
and mediators, rather than the treatment of disease entities.
Eliciting the Patient's Story
The first step in patient-centered care is eliciting the patient's story in a comprehensive manner. It
is the integrative practitioner's job to know not just the ailments or their diagnoses, but the
physical and social environment in which sickness occurs, the dietary habits of the person who is
sick (present diet and pre-illness diet), his beliefs about the illness, the impact of illness on social
and psychological function, factors that aggravate or ameliorate symptoms, and factors that
predispose to illness or facilitate recovery. This information is necessary for establishing an
integrated treatment plan.
The importance of understanding the patient's experience of his/her illness cannot be
overemphasized. Extensive research on doctor-patient interactions indicates that doctors who fail
to pay attention to the patient's concerns miss important clinical information. The conventional
diagnostic paradigm, differential diagnosis, leads doctors to ignore or denigrate information that
patients consider important, or that influences individual prognosis.2,3,4 Not only does this
ignorance impair the effectiveness of treatment,5 it generates considerable dissatisfaction among
patients.6,7,8
Extensive research done within the context of conventional medical care reveals what most
patients know: doctors do not pay enough attention to what their patients have to say. A study
done at the University of Rochester found that most patients have three reasons for visiting a
physician, are interrupted within eighteen seconds of starting to tell their stories, and never get
the chance to finish.9 Although doctors excuse this behavior by citing lack of time, it would have
taken an average of one minute and rarely more than three minutes for a complete list of
problems to be elicited.
Even when doctors know what their patients' concerns are, they typically ignore them.10 Most
patients have different ideas about their illnesses than their doctors and some form of
clarification or negotiation is needed for an effective therapeutic alliance to be established. 11 A
study that carefully analyzed taped transcripts of visits to a medical clinic found that patients
attempted to clarify or challenge what their doctor had said in 85% of the visits. Their requests
were usually ignored or interrupted.12 Understanding the patient's perspective allows the doctor
to work in a collaborative way with patients, giving information that helps the patient make
healthful choices.13 The more information the patient receives from the doctor and the more
actively the patient is involved in making decisions about treatment, the higher the level of
mutual satisfaction, and the better the clinical outcome.14,15,16,17,18 A systematic review of
randomized clinical trials and analytic studies of physician-patient communication confirmed a
positive influence of quality communication on health outcomes.19 Such a collaborative
relationship depends upon the practitioner recognizing and acknowledging the patient's
experience of the illness. Useful questions to ask include:
 How are you hoping that I can help you today?
 What do you believe is the source of your problems?
 What kind of treatment are you looking for?
 What do you most fear about your illness?
 What impact have your symptoms had on your life?
Organizing and Analyzing the Patient's Story
What modern science has taught us about the genesis of disease can be represented by three
words: triggers, mediators and antecedents. Triggers are discrete entities or events that provoke
disease or its symptoms. Microbes are an example. The greatest scientific discovery of the
nineteenth century was the microbial etiology of the major epidemic diseases. Triggers are
usually insufficient in and of themselves for disease formation, however. Host response is an
essential component. Identifying the biochemical mediators that underlie host responses was the
most productive field of biomedical research during the second half of the twentieth century.
Mediators, as the word implies, do not "cause" disease. They are intermediaries that contribute to
the manifestations of disease. Antecedents are factors that predispose to acute or chronic illness.
For a person who is ill, they form the illness diathesis. From the perspective of prevention, they
are risk factors. Knowledge of antecedents has provided a rational structure for the organization
of preventive medicine and public health. Medical genomics seeks to better understand disease
by identifying the phenotypic expression of disease-related genes and their products. The
application of genomic science to clinical medicine requires the integration of antecedents (genes
and the factors controlling their expression) with mediators (the downstream products of gene
activation). Mediators, triggers, and antecedents are not only key biomedical concepts, they are
also important psychosocial concepts. In person-centered diagnosis, the mediators, triggers and
antecedents for each person's illness form the focus of clinical investigation.
Antecedents and the Origins of Illness
Understanding the antecedents of illness helps the physician understand the unique
characteristics of each patient as they relate to his current health status. Antecedents may be
thought of as congenital or developmental. The most important congenital factor is gender:
women and men differ markedly in susceptibility to many disorders. The most important
developmental factor is age: what ails children is rarely the same as what ails the elderly. Beyond
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these obvious factors lies a diversity as complex as the genetic differences and separate life
experiences that distinguish one person from another.
Congenital factors may be inherited or acquired in utero. They can most readily be evaluated
from a comprehensive family history, including mother's health before and during pregnancy.
Genomic analysis, which is now commercially available, can supplement the family health
history as a tool for investigating unique nutritional needs or individual variability in sensitivity
to environmental toxins.20,21 The commonest single gene disorders in North America, celiac
disease and hemochromatosis, may be confirmed by the presence of genetic markers, but should
first be suspected from abnormalities in routine lab tests. Elevated serum ferritin concentration or
transferrin saturation should prompt genetic testing for the alleles associated with hereditary
hemochromatosis.22 Increased small intestinal permeability, as measured by the inexpensive,
non-invasive and under-utilized lactulose/mannitol challenge test, has a sensitivity approaching
100% for untreated celiac disease.23 Abnormal intestinal permeability should prompt the
measurement of celiac-specific immune markers in patients with chronic fatigue, autoimmune
disorders, or chronic gastrointestinal complaints of any type.
Normal intestinal permeability in patients consuming gluten almost always excludes celiac
disease as a consideration; however, this may not necessarily be the case for other glutensensitive disorders. Because celiac disease and gluten-sensitive disorders are common, have
protean manifestations, and can be well controlled by nutritional interventions, intestinal
permeability should be a routine component of the laboratory testing for antecedents of illness.
The treatment of choice for frank hemochromatosis is phlebotomy, but mild iron overload
without frank hemochromatosis is more common than the full-blown disease. These patients
generally have only one of the alleles associated with the disease, but have elevated transferrin
saturation and/or ferritin. They are not treated with phlebotomy, and should be treated with
dietary interventions. They should not take iron or vitamin C supplements, because vitamin C
reduces iron to its more toxic form.
Some familial disorders may reflect intra-uterine rather than genetic influences. Twin studies of
hypertension, for example, indicate a higher concordance for blood pressure between identical
twins with a common placenta than identical twins with separate placentas.24 Presumably, the
shared placenta mediates subtle nutritional influences that affect a tendency toward chronic
illness in adulthood.
Post-natal developmental factors that govern the predisposition to illness include nutrition,
exposure to toxins, trauma, learned patterns of behavior, and the microbial ecology of the body.
Sexual abuse in childhood, for example, is associated with an increased risk of abdominal and
pelvic pain syndromes among women.25,26 Recurrent otitis media increases the risk of a child
developing attention deficit disorder,27,28 an effect that is not associated with hearing loss but
may result from the effects of antibiotics on the microbial ecology of the gut.
Precipitating events are critical antecedents that closely precede the development of chronic
illness. They represent a boundary in time: before this event, the person was considered healthy;
since the event, the person has become a patient. Understanding the nature of the precipitating
event may aid in unraveling the triggers and mediators that maintain the state of illness. The
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commonest precipitating events among my patients are a period of severe psychosocial distress,
an acute infection (sometimes treated with antibiotics), exposure to environmental toxins at work
or home, or severe nutrient depletion related to illness or crash dieting. Useful questions for
uncovering precipitating events include:
 When is the last time you felt really well for more than a few days at a time?
 During the six months preceding that date, did you experience any illness or major stress,
change your use of medication or dietary supplements, or make any significant life changes?
Other publications of this author present cases in which cryptogenic illness was found to be
precipitated by foreign travel, antibiotic use, dietary changes,29 smoldering infection, or the
illness of a spouse.30
Triggers and the Provocation of Illness
A trigger is anything that initiates an acute illness or the emergence of symptoms. The distinction
between a trigger and a precipitating event is relative, not absolute; the distinction helps organize
the patient's story. As a general rule, triggers only provoke illness as long as the person is
exposed to them (or for a short while afterward), whereas a precipitating event initiates a change
in health status that persists long after the exposure ends. Common triggers include physical or
psychic trauma, microbes, drugs, allergens, foods (or even the act of eating or drinking),
environmental toxins, temperature change, stressful life events, adverse social interactions, and
powerful memories. For some conditions, the trigger is such an essential part of our concept of
the disease that the two cannot be separated; the disease is either named after the trigger (e.g.,
"Strep throat") or the absence of the trigger negates the diagnosis (e.g., concussion cannot occur
without head trauma). For chronic ailments like asthma, arthritis, or migraine headaches,
multiple interacting triggers may be present. All triggers, however, exert their effects through the
activation of host-derived mediators. In closed head trauma, for example, activation of NMDA
receptors, induction of nitric oxide synthase (iNOS), and liberation of free intra-neuronal calcium
determine the late effects. Intravenous magnesium at the time of trauma attenuates severity by
altering the mediator response.31,32 Sensitivity to different triggers often varies among persons
with similar ailments. A prime task of the integrative practitioner is to help patients identify
important triggers for their ailments and develop strategies for eliminating them or diminishing
their virulence.
Although the identification and elimination of triggers is not a foreign concept in conventional
medicine, many physicians neglect the search. A study was conducted by telephone in which
practicing physicians were asked how they would treat a new patient with abdominal pain, who
had a recent diagnosis of gastritis made by a specialist in another town. Almost half were ready
to put the patient on acid-lowering therapy without asking about the patient's use of aspirin,
alcohol or tobacco, all of which are potential triggers for gastritis. The authors of the study
concluded, "In actual practice, ignoring these aspects of the patient may well have reduced or
even negated the efficacy of other therapeutic plans implemented."33
Mediators and the Formation of Illness
A mediator is anything that produces symptoms, damage to tissues of the body, or the types of
behaviors associated with being sick. Mediators vary in form and substance. They may be
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biochemical (like prostanoids and cytokines), ionic (like hydrogen ions), social (like
reinforcement for staying ill), psychological (like fear), or cultural (like beliefs about the nature
of illness). A list of common mediators is presented in Table 1. Illness in any single person
usually involves multiple interacting mediators. Biochemical, psychosocial, and cultural
mediators interact continuously in the formation of illness.
Table 1 Common Illness Mediators
Biochemical
Hormones
Neurotransmitters
Neuropeptides
Cytokines
Free radicals
Transcription factors
Subatomic
Ions
Electrons
Electrical and magnetic fields
Cognitive/emotional Fear of pain or loss
Feelings or personal beliefs about illness
Poor self-esteem, low perceived self-efficacy
Learned helplessness
Lack of relevant health information
Social/cultural
Reinforcement for staying sick
Behavioral conditioning
Lack of resources due to social isolation or poverty
The nature of the sick role and the doctor/patient relationship
Cognitive/emotional mediators determine how patients appraise symptoms and what actions they
take in response to that appraisal.34 They may even modulate the symptoms themselves. People
in pain, for example, experience more pain when they fear that pain control will be inadequate
than when they believe that ample pain management is available.35
Perceived self-efficacy (the belief in one's ability to cope successfully with specific problems) is
a cognitive mediator that determines coping with illness. People with a high degree of health
self-efficacy usually adapt better to chronic disease, maintaining higher levels of activity,
requiring lower doses of pain medication, adopting healthier lifestyles, and cooperating with
prescribed therapies, compared to people with low self-efficacy.36 Self-management education is
designed to enhance self-efficacy,37 and has been shown to improve the clinical outcome for
patients with several types of chronic disease, including asthma,38 arthritis,39,40,41 and diabetes.42
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The biochemical mediators of disease listed in Table1 are best known for their ability to promote
cellular damage. Most are organized into circuits and cascades that sub-serve homeostasis and
allostasis. In these networks, each mediator is multi-functional and most functions involve
multiple mediators, so that redundancy is the rule, not the exception. The most striking
characteristic of biochemical mediators is their lack of disease specificity. Each mediator can be
implicated in many different, apparently unrelated diseases, and every disease involves multiple
chemical mediators in its formation.
Mediator networks that regulate inflammatory and neuroendocrine stress responses have been
the subject of intensive research with important clinical implications. Comprehensive reviews
have appeared elsewhere.43,44,45,46 Within the framework of integrated medicine, a key feature of
biochemical mediators is the natural rhythm of mediator activity, which is strongly influenced by
the common components of life: diet, sleep, exercise, hygiene, social interactions, solar and lunar
cycles, age, and sex. Aging, illness, and chronic psychological distress up regulate activity of the
inflammatory and neuroendocrine-stress response networks. Regular physical activity down
regulates both.
Integrating the Patient's Story
After listening to the concerns that led each patient to seek a consultation in integrated medicine,
the clinician makes a series of distinctions:
1) For patients whose main concern is optimal health and prevention, ask about present and past
health problems and the family health history. If these supply no indication of illness
susceptibility, then turn your attention to risk factors for future illness: weight, fitness, type
and level of physical activity, dietary pattern, sleep habits, use of alcohol, drugs, tobacco,
firearms, environmental exposures at home and work, travel, sources of stress and pleasure,
degree of involvement with others, spiritual beliefs and practices, sexual relationships, hopes
and fears for the future.
2) For patients with an active health problem, always ask, "What was your health like before
this problem began?" An intake questionnaire that asks about previous health problems is
also helpful, because it gathers information in a different fashion concerning what the patient
was like prior to the present illness. Such a tool is condition-specific, not open-ended. The
two approaches complement one another.
a) Some patients will say that they were really healthy prior to their present illness. In that
case, look for a precipitating event. If you or the patient can identify one, then ask about
ongoing triggers that bear some relationship to the precipitating event. For example: if the
precipitating event was marital or job stress, focus on stress-related psychological
triggers. If the precipitating event was an environmental exposure, focus on on-going
exposures to volatile chemicals or mold.
b) The most challenging patients will usually indicate that their health was poor even before
their present illness. In that case, take a detailed, chronological history from birth to the
present that includes information about early life experience (including illness, injury and
abuse), school and work performance, diet, drug and medication use, leisure activities,
travel, family life, sexual experiences, habits, life stressors and places of residence.
Because gathering this data can be very time consuming, a self-administered
questionnaire completed by the patient before the interview may help to prompt
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responses and improve memory of remote events. For many patients with complex,
chronic health problems, it may be useful to take a detailed life history before seeking
detailed information about present symptoms. Problems that emerge from such a review
have to be addressed for a successful outcome of treatment. Dealing with the present
concerns by themselves almost never succeeds for patients in this group.
Whatever rapport you establish with patients initially, maintaining the therapeutic relationship
usually depends upon significant improvement in symptoms or in a sense of well being within a
few days to a few weeks of the initial evaluation. Addressing the triggers that provoke symptoms
and helping the patient decrease exposure to them most efficiently achieve this. When triggers
cannot be identified or avoided, then symptomatic improvement must rest on control of mediator
activation. A combination of the two will usually produce the most satisfactory long-term
benefits.
Assessment of Triggers
A comprehensive search for triggers requires that you know the following about your patient:
each drug—prescription, over-the-counter or recreational—that the patient has used and when;
nutritional habits and each dietary supplement used and when; what effects the patient noted
from the use of each substance; sources of stress—life events, environmental exposures, thoughts
or memories, and social interactions—and when they occurred in relation to symptoms. Elicit the
patient's own ideas about possible triggers by asking, "What do you think causes or aggravates
your symptoms?" The patient's observations may be insightful and accurate in ascribing
causality. Of course the patient’s—and the clinician’s—observations can also mislead, or focus
on non-essential factors. Teach patients to challenge their own observations by looking for
consistency and replicability, wherever possible. Suggest alternative theories for the patient to
consider and explain that the search for triggers works best as a collaborative effort between
patient and doctor. The patient's ability to recognize triggers is an important step in self-care.
Food and environment supply important triggers for the practice of integrated medicine. Food
intolerance is a very common phenomenon, reported by thirty-three per cent of the population in
one large study.47 Relatively few of these reactions (4-14%) are due to true food allergies. Most
food intolerance has no clear immunologic basis. Mechanisms include sensitivity to the
pharmacological effect of alkaloids, amines or salicylates in food.48,49,50,51Histamine poisoning
from scombroid fish and tyramine-induced headache are dramatic examples.52 Although most
food intolerance is short-lived, severe chronic illness can occur, and the food trigger may elude
identification unless the physician starts the investigation with a high index of suspicion. Gluten
intolerance, with its protean manifestations, is probably the best example. Affecting about two
per cent of people of European ancestry,53 gluten intolerance is common and often unrecognized.
In addition to being the essential trigger for celiac disease, gluten sensitivity may be manifest in
patients with neurological disorders of unknown cause,54 cerebellar degeneration,55 dermatitis
herpetiformis,56 failure to thrive,57 pervasive developmental delay,58 inflammatory
arthritis,59,60,61,62,63 psoriasis,64,65 Sjögren’s syndrome,66,67 and schizophrenia.68,69 The different
presentations of gluten sensitivity may derive from genetic differences among affected patients. 70
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Published studies on food intolerance and your patients' symptoms may be found through the
National Library of Medicine. If the patient has a disease diagnosis, an Internet search may
reveal previously observed associations between specific foods and the patient's condition.
Access PubMed over the Internet (www.pubmed.gov) and run a search that cross-references the
name of the patient's condition with "Hypersensitivity, Food" and also with "Food, adverse
reactions.” Both of these are Medline Subject Headings (MESH). There is no MESH listing for
"Food Allergy" or "Food Intolerance.” Your search will be more efficient if you list the patient's
condition as it appears in MESH. A negative search does not eliminate food intolerance as a
trigger for the condition being searched, but the number of positive findings may surprise you.1
Health effects of ambient air quality are as important as those of foods. Numerous studies
conducted in U.S. cities demonstrate a close correlation between fine particle air pollution and
daily mortality rates, even at levels of pollution considered safe by the World Health
Organization.71 In the industrialized world, most people spend most of their time indoors, and
indoor air pollution has become a serious cause of morbidity. Studies using experimental
chambers have shown that volatile organic compounds (VOCs) released from building materials,
furnishings, office machines, and cleaning products can cause irritation of the respiratory system
in humans and animals at levels which are one hundred times weaker than permissible exposure
levels or the World Health Organization Indoor Air Guidelines.72,73,74 Controlled experiments
with people who describe themselves as sensitive to VOCs confirm that VOC exposure causes
headache, fatigue, and difficulty concentrating. People who deny such sensitivity also experience
symptoms but do not experience mental impairment when exposed. Air samples of buildings
with and without “sick building” complaints have established an association between VOC
exposure and human sickness.75,76,77,78
A questionnaire can elicit important information about environmental exposures at home and at
work. The open-ended question, "Has your work or home environment been a concern to you?"
should be accompanied by a checklist of potential exposures.
Microbial triggers for chronic illness present a particular challenge, as exemplified by the many
facets of Helicobacter pylori infection. Originally isolated from the gastric mucosa of patients
with gastritis and peptic ulcer disease, H. pylori has been implicated in the pathogenesis of
NSAID gastropathy,79 gastric carcinoma,80 lymphoma,81 and a variety of extra-digestive
disorders, including ischemic heart disease,82 ischemic cerebrovascular disorders,83 rosacea,84
Sjögren’s syndrome,85 Raynaud's syndrome,86 food allergy,87 vitamin B12 deficiency,88 and open
angle glaucoma.89 For elderly patients with open angle glaucoma and incidental H. pylori
infection of the stomach, eradication of H. pylori by antibiotics was associated with improved
control of glaucoma parameters at two years.90 The mechanism by which H. pylori aggravates
open-angle glaucoma is unknown, but may result from the ability of H. pylori colonization of the
gastric tract to trigger the local and systemic release of platelet-activating factor, inflammatory
cytokines, and vasoactive substances.
In the case of untreated H. pylori infection, non-invasive screening tests, including serum
antibodies, stool antigens, and C-14 breath testing, are available. For other types of infection,
1
Medical cybrarian Valerie Rankow (vgr99@optonline.net) has assisted the author with this search strategy and
with numerous other, more complex searches.
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inquiring about the previous response of a given symptom or symptom complex to antibiotics
may be useful. In 1988, physicians at the University of Minnesota conducted a study in which
they administered intravenous cephalosporins to patients with various types of arthritis who also
manifested antibodies to Borrelia burgdorferi. Most of these patients were not thought to have
Lyme disease. Some met diagnostic criteria for rheumatoid arthritis, some for osteoarthritis, and
some for spondyloarthropathies. The response to antibiotics was quite variable and ranged from
no response to dramatic and sustained improvement. The authors noted that improvement in
arthritis following antibiotics was not related to the patient's clinical diagnosis or the level of
anti-Borrelia antibody. The best predictor of a positive response to the experimental treatment
was a previous history of improvement of arthritis associated with the use of antibiotics.91
The most comprehensive way to ask the antibiotic question is: "During the time you have had
symptom X, have you taken antibiotics for any reason? Which antibiotic? Did symptom X
change while you were taking the drug?" Among patients with chronic diarrhea of unknown
cause, for example, some will report that their gastrointestinal symptoms improved when taking
a specific antibiotic; others will report that they worsened. The first case suggests that bacteria or
protozoa sensitive to the antibiotic may be causally related to the patient's gastrointestinal
problems. Repeating the antibiotic prescription can establish if this response is replicable. If so,
therapy can focus on treating the microbe and understanding why a single course of antibiotics
was ineffective. The second case suggests that depletion of bacteria by antibiotics and
concomitant increase in antibiotic-resistant organisms, including yeasts, may be contributing to
diarrhea, and treatment can focus on restoration of normal intestinal flora.
Assessment of Psychosocial Mediators
Useful questions for eliciting a person's beliefs about his/her illness are:
"What do you think has caused your problem?"
"What do you most fear about your problem?"
"How much control do you think you have over your symptoms?"
Useful questions for eliciting information about the nature and sources of social support include:
"Are there people in whom you can confide?"
"How satisfied are you with your marriage/family/friends/social life?”
"How much support do you receive in dealing with your health problems?"
"How often do you feel loved or cared for?"
Assessment of Biochemical Mediators
Understanding the biochemical alterations associated with a conventional disease diagnosis can
be helpful in understanding the biochemical mediators of each person's illness. Inflammation is
believed to play a critical role not only in response to infection and in the classic inflammatory
diseases, but also in the pathogenesis of coronary artery disease, diabetes, cancer, depression,
and the negative health effects associated with obesity and with aging.92,93,94,95,96,97,98 The
orchestration of mediator signals in the inflammation and neuroendocrine-stress networks, as
they interact with one another, is critical for normal physiological functions (e.g., the architecture
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of sleep, the repair of injury, and the response to infection), and for the dysfunctional physiology
central to the pathogenesis of most of the major chronic diseases.99,100,101
Most chronic disease is associated with chronic inflammation, but the patterns of immune
response that underlie inflammation are not always the same. Patients with Type 1 diabetes
mellitus, Crohn's disease or any other disorder categorized by granuloma formation or excessive
cell mediated immune responses are likely to have an immune response to common triggers in
which the Th1 component is up regulated and not subject to the normal down regulation
provided by Th2 activity. Their mediator response to inflammatory stimulation produces
excessive levels of gamma-interferon (g-IFN) and interleukin-12 (IL-12), key Th1-related
cytokines.102 Patients with severe depression often show a loss of negative feedback in the HPA
axis. Urinary free cortisol is elevated;the diurnal pattern may be disrupted, with increased PM
cortisol secretion and blunting of dexamethasone suppression. This phenomenon appears to be
driven at the level of the hypothalamus, not the adrenals, because spinal fluid corticotrophin
releasing hormone (CRH) is elevated.103 Several groups of researchers in the late 1990s
speculated that impaired synaptic function due to a deficit of omega-3 fatty acids may contribute
to the CNS dysfunction of patients with depressive illness104,105,106,107 (although some large
recent studies do not show the same patterns108,109). Omega-3 fatty acid levels tend to be lower in
blood samples than in control populations. The key component appears to be eicosapentaenoic
acid (EPA).
To utilize the vast database of available information about biochemical disease mediators,
integrative clinicians should consider three strategies. First, maintain up-to-date knowledge of
disease pathophysiology by reading reviews in mainstream journals on mechanisms of disease or
on specific mediators. In reading these, pay special attention to the types of mediators mentioned
and their functions within the networks that involve inflammation, oxidative stress, and
neuroendocrine balance. Second, attend workshops and courses that emphasize integrative
physiology, sponsored by institutions like the New York Academy of Sciences. Third, employ
knowledge of the commonest biochemical imbalances in chronically ill North Americans and the
influence of diet, nutrition, and dietary supplements on these imbalances.
Treatment Planning
An integrated treatment plan should be collaborative and dynamic. Collaborative means that
patient and practitioner work together to set goals and priorities. Dynamic means that the
treatment plan is adjusted as needed in response to feedback. Your knowledge of the patient's
beliefs about his/her illness and perceived self-efficacy are essential for collaborative treatment.
An appropriate therapeutic intervention for dysfunctional beliefs is the giving of information.
Patients have an intense need for explanations about the causes of their diseases.110 They want to
know how they came to be sick, so that they can attach some meaning to the illness,111 what to
expect from the illness, and what they can do to relieve symptoms or speed recovery.
Information of this type can reduce anxiety (even when the diagnosis itself is frightening),
increase feelings of personal control, and improve the ability to cope with pain. People change
their behaviors more readily when they receive information about the importance and the nature
of the changes they need to make, help with setting goals, and measuring progress. The kind of
information needed is personal, not statistical. It must answer the question, "What can I do?"
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The physician can help patients who are suffering from isolation by calling this isolation to the
attention of family members or friends, or by attempting to connect the patient with a support
group or community agency. Possibly, there is nothing that can be done to relieve the patient's
isolation, but the doctor's awareness and acknowledgment of it can be important to the patient
and serve to enhance the therapeutic relationship.112
If potential triggers have been identified, an assessment of the patient's ability to control
exposure to them is important. For patients who are reluctant to make major dietary or
environmental changes, explain that each avoidance is an experiment that the patient can direct
with your guidance. If eliminating foods (and reintroducing those foods as a challenge) has no
effect on symptoms or measurable physiologic parameters do not encourage the patient to persist
in the avoidance of those foods, whatever the results of in vitro allergy tests may be. The patient
will have enough work to do following a healthy diet. Food intolerance is only meaningful if its
effects can be demonstrated in real life.
For microbial triggers, the decision to use prescription antimicrobial drugs or natural products
with antimicrobial activity may require negotiation. If the situation is not critical, it is usually
worthwhile honoring the patient's preferences and intuition.
Understanding the ways in which mediators are modulated by diet enables creative nutritional
therapies to be applied. Salicylic acid, the major metabolite of aspirin, suppresses activation of
the nuclear transcription factor NF-kB, an anti-inflammatory effect that is independent of
cyclooxygenase inhibition113 and may be responsible for some effects of low-dose aspirin
therapy.114 Vegetables are rich sources of natural salicylates and vegetarians may have serum
concentrations of salicylic acid as high as those of people ingesting 75 mg of aspirin a day.115
Dietary fatty acids may have profound effects on the network of inflammatory mediators,
altering prostanoid synthesis, PPAR activity, and the response to cytokines like IL-1.116,117,118
They have subtler effects on the neuroendocrine-stress response network, modulating neuronal
responses to serotonergic and adrenergic transmission.119 Therapy with omega-3 fatty acids
provides an excellent example of nutritional modulation of disease activity though alteration of
biochemical mediators.120 Three principles can guide this type of therapy. The first utilizes
knowledge of the pathophysiology of specific inflammatory and CNS disorders. Using this
model, omega-3 therapy has been successfully applied to the treatment of patients with
rheumatoid arthritis,121 inflammatory bowel disease,122 coronary artery disease,123 peripheral
vascular disease,124 dysmenorrhea,125 cystic fibrosis,126 migraine headaches,127
schizophrenia,128,129 atopic eczema,130 and multiple sclerosis.131,132 Because the fatty acid
composition of the contemporary Western diet differs significantly from Paleolithic and ancestral
diets, reflecting a marked decrease in omega-3 consumption relative to total fat, the response of
so many unrelated disorders to EFA supplementation may indicate that EFAs are not merely
working as nutriceutical agents, but that EFA dietary status is important for disease pathogenesis.
The second method rests upon the clinical evaluation of an individual’s fatty acid status using
clinical parameters that are independent of disease activity. Prasad has stated that the best test for
nutritional adequacy is a functional test.133 Determine a parameter to follow and measure how
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administration of the nutrient(s) in question affects that parameter. This method can be applied to
the use of EFA therapy in clinical practice. Stevens et al., studying boys with ADHD and a
randomly selected population of schoolchildren, found a correlation between low concentrations
of omega-3 EFAs, learning and behavior problems, and symptoms associated with EFA
deficiency (thirst, dry skin, and dry hair).134,135 Evaluating the presence of these symptoms in
patients and observing how they change with EFA supplementation is a quick guide to EFA
status that may be used clinically to evaluate the EFA contribution to mediator imbalance. This
author's method for doing this has been described elsewhere.136 Finally, it is possible to measure
the levels of fatty acids in plasma and erythrocyte phospholipids, although guidelines for level of
change in fatty acid profiles needed to produce a known clinical effect have only been reported
for patients with rheumatoid arthritis, in whom clinical improvement requires that
eicosapentanoic acid (EPA) account for 5% of fatty acids in plasma phospholipids.137
The successful application of nutritional therapies, especially dietary interventions, and other
self-care practices, as part of a therapeutic plan is very helpful in enhancing self-efficacy among
patients. Enhancement of self-efficacy should always be a cardinal goal of treatment in
integrated medicine.
Summary
Integrated medicine is essentially patient centered, rather than disease centered. A structure is
presented for uniting a patient-centered approach to diagnosis and treatment with the fruits of
modern clinical science (which evolved primarily to serve the prevailing model of diseasecentered care). The core scientific concepts of disease pathogenesis are antecedents, triggers, and
mediators. Antecedents are factors, genetic or acquired, that predispose to illness; triggers are
factors that provoke the symptoms and signs of illness; and mediators are factors, biochemical or
psychosocial, that contribute to pathological changes and dysfunctional responses.
Understanding the antecedents, triggers and mediators that underlie illness or dysfunction in each
patient permits therapy to be targeted to the needs of the individual. The conventional diagnosis
assigned to the patient may be of value in identifying plausible antecedents, triggers or mediators
for each patient, but is not adequate by itself for the designing of patient-centered care.
Applying the model of Person-Centered Diagnosis to patients facilitates the recognition of
disturbances that are common in people with chronic illness. Diet, nutrition, and exposure to
environmental toxins play central roles in integrated medicine because they may predispose to
illness, provoke symptoms, and modulate the activity of biochemical mediators through a
complex and diverse set of mechanisms.
A patient's beliefs about health and illness are critically important for self-care and may influence
both behavioral and physiological responses to illness. Perceived self-efficacy is an important
mediator of health and healing. Enhancement of patients' self-efficacy through information,
education, and the development of a collaborative relationship between patient and healer is a
cardinal goal in all clinical encounters.
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